Annual medical deductible,
in-network and out of network combined, applies towards annual out-of-pocket
maximum |
In-Network
|
$500 annual deductible for all medical
services except office visits; two-member family maximum |
Out-Of-Network
|
$500 annual deductible for all medical
services except office visits; two-member family maximum |
| Lifetime
covered charges paid by Blue Cross, in-network and out-of-network
combined |
In-Network
|
$5,000,000 |
Out-Of-Network
|
$5,000,000 |
Annual
out-of-pocket maximum
Certain payments do not apply |
In-Network
|
$4,500 per member; two-member family
maximum |
Out-Of-Network
|
Once Blue Cross payments reach $10,000,
member pays nothing for covered expenses for the remainder of the
year |
Office
visits
Not subject to deductible |
In-Network
|
$40 co pay for initial 12 office visits
per member, additional office visits 45% of negotiated fee |
Out-Of-Network
|
50% of the negotiated fee, plus 100%
of charges in excess of the negotiated fee |
| Other
professional services, including maternity, diagnostic lab and x-ray |
In-Network
|
40% of the negotiated fee after annual
deductible |
Out-Of-Network
|
50% of the negotiated fee, plus 100%
of charges in excess of the negotiated fee after annual deductible |
Hospital
inpatient facility services
Pre service Review required |
In-Network
|
PREFERRED PARTICIPATING HOSPITALS: 40%
of the negotiated fee after annual deductible
PARTICIPATING HOSPITALS: 40% of the negotiated fee |
Out-Of-Network
|
Member pays all charges except $650
per day after annual deductible |
| Hospital
inpatient professional services (lab, physician, anesthesia) |
In-Network
|
40% of the negotiated fee after annual
deductible |
Out-Of-Network
|
50% of the negotiated fee, plus 100%
of charges in excess of the negotiated fee after annual deductible |
Hospital
outpatient services
Pre service Review required for certain surgeries and diagnostic
procedures |
In-Network
|
PREFERRED PARTICIPATING HOSPITALS: 40%
of the negotiated fee after annual deductible
PARTICIPATING HOSPITALS: 40% of the negotiated fee plus $500 admission
charge for surgeries or infusion therapy after annual deductible |
Out-Of-Network
|
Member pays all charges except $380
per day after annual deductible |
Ambulatory
Surgical Centers
Pre service Review required |
In-Network
|
40% of the negotiated fee after annual
deductible |
Out-Of-Network
|
Member pays all charges except $380
per day after annual deductible |
Prescription
Drugs
30-day supply retail; Up to a 60-day supply available through mail
order |
In-Network
|
$15 co pay generic
(for each 30-day supply), $25 co pay brand (for each 30-day supply)
after annual $150 brand name prescription drug deductible per
member, in-network and out-of-network combined; infertility drug
lifetime maximum benefit $1,500 in-network and out-of-network
combined; self-administered injectable drugs, except Insulin,
30% of the negotiated fee (subject to brand name prescription
drug deductible if applicable)
If you select a brand-name drug when a generic equivalent drug
is available, even if the physician writes a "dispense as written"
or "do not substitute" prescription, the member will be responsible
for the generic co pay plus the difference in cost between the
brand-name and the generic equivalent drug. * |
Out-Of-Network
|
50% of Drug Limited
Fee Schedule if filled within California after annual $150 brand
name prescription drug deductible per member, in-network and out-of-network
combined; infertility drug lifetime maximum benefit $1,500 in-network
and out-of-network combined |
Healthy
Check screenings, Ages 7-adult
Includes certain lab tests, immunizations and health education information |
In-Network
|
NOT SUBJECT TO ANNUAL DEDUCTIBLE
$25 or $75 co pay health screening options |
Out-Of-Network
|
Not Available |
Well-baby
immunizations and adult screening tests
CHILDREN THROUGH AGE 6: Regular check-up and immunizations
AGES 7-ADULT: limited to annual pap, breast exam, and mammogram
for women and Prostate Specific Antigen (PSA) study for men |
In-Network
|
$40 co pay for office visit; 40% of
the negotiated fee for all other covered services after annual deductible |
Out-Of-Network
|
50% of the negotiated fee, plus 100%
of charges in excess of the negotiated fee after annual deductible |
Emergency
Care
$100 co pay for each visit - waived if admitted |
In-Network
|
PREFERRED PARTICIPATING HOSPITALS AND
PARTICIPATING HOSPITALS:
40% of the negotiated fee after annual deductible |
Out-Of-Network
|
40% of customary and reasonable charges,
plus 100% of excess for first 48 hours; after 48 hours, all charges
in excess of $650 per day after annual deductible |
| Ambulance |
In-Network
|
40% of the negotiated fee after annual
deductible |
Out-Of-Network
|
50% of the negotiated fee, plus 100%
of charges in excess of the negotiated fee after annual deductible |
Skilled
Nursing Facility
100 days per year; in-network and out-of-network combined Pre service
Review required |
In-Network
|
40% of the negotiated fee after annual
deductible |
Out-Of-Network
|
All charges except $150 per day after
annual deductible |
Home
Health Care
90 four-hour visits per year; in-network and out-of-network combined
Pre service Review required |
In-Network
|
40% of the negotiated fee after annual
deductible |
Out-Of-Network
|
All charges except $75 per visit after
annual deductible |
Physical/Occupational
Therapy, Chiropractic Care
12 visits a year; in-network and out-of-network combined |
In-Network
|
40% of the negotiated fee after annual
deductible |
Out-Of-Network
|
All charges except $25 per visit after
annual deductible |
Acupuncture/Acupressure
12 visits a year; in-network and out-of-network combined |
In-Network
|
All charges except $25 per visit after
annual deductible |
Out-Of-Network
|
All charges except $25 per visit after
annual deductible |
Mental
Health*, including Chemical Dependency Inpatient:
30 days per year; in-network and out-of-network combined |
In-Network
|
All of the negotiated fee except $175
per day after annual deductible |
Out-Of-Network
|
All charges except $175 per day after
annual deductible |
Mental
Health*, including Chemical Dependency Outpatient professional services:
One visit per day, 20 visits per year; in-network and out-of-network
combined |
In-Network
|
All of the negotiated fee except $25
per visit after annual deductible |
Out-Of-Network
|
All charges except $25 per visit after
annual deductible |
Infusion
Therapy, including Chemotherapy
Pre service Review required |
In-Network
|
40% of the negotiated fee after annual
deductible |
Out-Of-Network
|
50% of the negotiated fee, plus all
charges in excess of $50 per day for all infusion therapy expenses
except drugs; all charges in excess of the average wholesale price
for all infusion therapy drugs; all charges in excess of the combined
covered maximum Blue Cross payment of $500 per day after annual
deductible |
Infertility
Maximum lifetime benefit $2,000, in-network and out-of-network combined |
In-Network
|
$500 co pay; plus 40% of the balance
of the negotiated fee after annual deductible |
Out-Of-Network
|
$500 co pay; plus 50% of the balance
of the negotiated fee, plus 100% of charges in excess of the negotiated
fee after annual deductible |
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